Metal-on-metal bearings in cementless primary total hip arthroplasty

doi:10.1016/j.arth.2004.09.002

The Journal of Arthroplasty

Volume 19, Issue 8, Supplement, December 2004, Pages 35-40

https://doi.org/10.1016/j.arth.2004.09.002 Get rights and content

Abstract

One hundred cementless titanium primary total hip arthroplasties with 28 mm Metasul bearings were prospectively studied (osteoarthritis in 76% of hips, mean age 59.6 years). Ninety-eight were reviewed after a 6-year average follow-up (range, 17–126 months) with clinical results graded excellent and good in 97%. One femoral component was revised for aseptic loosening at 7.8 years. Postoperative cobalt level was higher than the upper “normal” value (5 μg/L in whole blood) for 16 cases. No significant relationship could be established between cobalt concentration increase and any demographic or surgical data, including activity level, except anteversion of the cup >25°. In this early experience, impingement due to a head sleeve has been the main cause of dislocation and failure, and systemic cobalt survey appeared to be a good indicator of metal-on-metal bearing mechanical behavior.

Section snippets

Material and methods

From January 1994 to March 1999, 100 cementless primary Alloclassic-Metasul THA (Zimmer GmbH) (proximally hydroxyapatite coated in 9 stems) with threaded CSF cups (Fig. 1) were prospectively studied. They represent 55% of all primary THA performed by the same surgeon during the study period. The first 22 THAs had an early-generation Metasul couple (with femoral head sleeves) and the subsequent 78 THAs had the currently available Metasul bearing (without head sleeves).

Complications

Postoperatively, 1 phlebitis was successfully treated with prolonged anticoagulation. There were 1 early and 4 late (more than 4 months following surgery) dislocations (5%). Three were treated by closed reduction with no recurrence thus far. Two of the 4 hips that dislocated late were revised for the following reasons. In a 69-year-old male patient, dislocation occurred 2.9 years after surgery, but closed reduction was unsuccessful and required reoperation. At surgery, the metallic ball was

Dislocation with metal-on-metal bearings

In this series, the dislocation rate of metal-on-metal THAs (5%) was quite high. Of the 5 hips that dislocated, 3 belonged to the group of 22 hips with head sleeves. Since 1995, when the original Metasul head sleeve design was replaced by the current ball that had no sleeve, the author has observed a reduction in dislocation rate between THAs with sleeve head (13.6%) and THAs without sleeve (2 out of 78, 2.6%). Nevertheless, this difference does not reach the level of significance (P=.12).

In a

Acknowledgements

The author thanks Mrs. Hassan Achakri and Daniel Reyner for their help in statistical analysis and Pat Campbell and Paul Beaulé for their considerable help in the editing process.

References (18)

P.A. Devane et al.
Three-dimensional polyethylene wear of a press-fit titanium prosthesis. Factors influencing generation of polyethylene debris
J Arthroplasty
(1997)
K.-H. Widmer
A simplified method to determine acetabular cup anteversion from plain radiographs
J Arthroplasty
(2004)
H. Malchau et al.
The Swedish total hip replacement register
J Bone Joint Surg Am
(2002)
C. Delaunay et al.
Survival analysis of cementless grit-blasted titanium total hip arthroplasties
J Bone Joint Surg Br
(2001)
F. Bonnomet et al.
Straight femoral taper in cementless primary total hip replacement in less than 65 year-old patientsmulticenter study of 115 consecutive implantations at mean 8.2 year follow-up
Rev Chir Orthop
(2001)
B.G. Weber
Experience with the Metasul total hip bearing system
Clin Orthop
(1996)
J.J. Jacobs et al.
Metal degradation productsa cause for concern in metal-metal bearings?
Clin Orthop
(2003)
J. Nevelos et al.
Metallurgical considerations in the wear of metal-on-metal hip bearings
Hip International
(2004)
R. Merle d’Aubigne
Cotation chiffrée de la fonction de la hanche
Rev Chir Orthop
(1970)

There are more references available in the full text version of this article.

Cited by (77)

Long-term survival of hybrid total hip arthroplasty with the uncemented CLS cup, cemented Müller cobalt-chromium stem, and 28-mm Metasul™ bearings: Retrospective review of 115 hips after a minimum of 17.8 years
2019, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
In the 1980s, after a study of metal-on-metal (MoM) McKee-Farrar THAs, Weber et al. [3,4] worked with Sulzer Medical Technology (Winterthur, Switzerland) to develop a second-generation small-head MoM implant, whose high carbon content was designed to minimise wear. In the first clinical studies, 10-year survival was 97.9% to revision for any reason and 100% to aseptic loosening [5]. In contrast, when this small-head MoM bearing is used with a cup cemented directly onto the bone with no backing, the risk of loosening is increased [6].
Hard-on-hard bearings require a meticulous implantation technique but may be associated with lower wear rates in young active patients. Among them, metal-on-metal (MoM) bearings have been blamed for specific complications including adverse reactions to metal debris and metal hypersensitivity. These complications have been chiefly reported with large-head MoM implants (except when used for hip resurfacing). Most of the published data on small-head MoM implants were obtained using uncemented stems. To our knowledge, no information on outcomes beyond 15 years is available for small-head MoM implants with cemented cobalt-nickel-chromium (Co-Ni-Cr) stems, which might increase the risk of complications. The objective of this study was to collect long-term follow-up data on patients who underwent hybrid total hip arthroplasty (THA) with 28-mm MoM Metasul™ bearings in order to assess: (1) long-term survival (based on the revision rate), (2) and the occurrence of adverse reactions to metal debris documented during revision.
Survival of 28-mm Metasul™ bearings used with hybrid THA is acceptable.
A single-centre retrospective study was conducted in consecutive patients managed using 28-mm Metasul™ bearings in a press-fit cup, with a cemented Co-Ni-Cr stem. Follow-up was at least 17 years. The clinical and radiographic data were analysed. Mean age at surgery was 57.3 ± 7.9 years (range, 29.6–75.3 years).
The study included 115 hips with a mean follow-up of 20.3 ± 0.8 years (range, 17.8–21.6 years). Survival to revision for any reason was 86.10% (95% CI, 79.8–92.4%) and survival to revision for aseptic loosening was 92.6% (95% CI, 87.7–97.6). Half the specimens obtained during revision showed a macrophage reaction and a non-specific inflammatory infiltrate. No patient experienced complications specifically related to the use of Metasul™ bearings with a cemented Co-Ni-Cr stem.
Long-term survival of 28-mm MoM Metasu™ bearings was close to that of metal-on-polyethylene bearings and lower than that of ceramic-on-ceramic or small-head MoM bearings in other studies. No complications specifically related to the use of small-head MoM bearings with a cemented Co-Ni-Cr stem were recorded.
IV, retrospective study.
Long-Term survival of hybrid total hip arthroplasty with the uncemented CLS cup, cemented Müller Cobalt-Chromium Stem, and 28-mm Metasul™ bearings: Retrospective review of 115 hips after a minimum of 17.8 years
2019, Revue de Chirurgie Orthopedique et Traumatologique
Les couples de frottement dur-dur exigent une implantation rigoureuse, mais ils peuvent être bénéfiques en terme de résistance à l’usure pour les patients jeunes et actifs. Parmi ces couples le métal-métal (MoM) a été incriminé dans la survenue de complications spécifiques telles que des réactions indésirables aux débris métalliques ou une hypersensibilité, principalement avec les arthroplasties MoM de grand diamètre (hors resurfaçage). La plupart des séries se rapportant au MoM en petit diamètre utilisent un pivot sans ciment, et à notre connaissance il n’y a pas de résultats au-delà de 15 ans de recul du MoM petit diamètre sur un pivot cimenté en Chrome-Nickel-Cobalt (Cr-Ni-Co) ce qui pourrait favoriser la survenue de complications. Aussi nous avons mené une analyse à long terme du Metasul en calibre 28 mm équipant une arthroplastie hybride de ce type afin (1) d’évaluer la survie à long terme (taux de reprises), (2) la survenue potentielle de réactions aux débris observé lors d’une reprise.
Notre hypothèse était que le couple métal-métal Métasul en calibre 28 mm dans cette configuration hybride dispose d’une survie acceptable.
Nous avons mené une étude rétrospective continue monocentrique incluant tous les patients ayant eu un Metasul™ de 28 mm de diamètre dans une cupule pressfit associée à un pivot en Cr-Ni-Co cimenté, avec un recul minimum de 17 ans et une analyse clinique et radiographique. L’âge moyen à la chirurgie était de 57,3 ans ± 7,9 [29,6–75,3].
Au recul moyen de 20,3 ans ± 0,8 ans [6,8–17,17–21], nous avons évalué 115 hanches, le taux de survie était de 86,10 %% [IC 95 % : 79,8–92,4] pour la reprise toutes causes confondues et de 92,6 % [IC 95 % : 87,7–97,6] pour reprise pour descellement aseptique. La moitié des reprises a révélé une réaction des macrophages et un infiltrat inflammatoire aspécifique. Nous n’avons pas eu de complication spécifique sur cette série liée à l’usage du Metasul sur un pivot en Cr-Ni-Co cimenté.
La survie à long terme du couple Metasul™ MoM de 28 mm de diamètre était proche de celle des couples métal-polyéthylène et inférieure à celle des couples céramique-céramique ou MoM petit calibre dans d’autres études. Nous n’avons pas retrouvé de complications spécifiques à l’usage du MoM de petit calibre, notamment en association avec un pivot en Cr-Ni-Co cimenté.
IV, étude rétrospective
Metal on Metal or Ceramic on Ceramic for Cementless Total Hip Arthroplasty: A Meta-Analysis
2016, Journal of Arthroplasty
Citation Excerpt :
Among 59 studies, 3 articles directly compared MOM and COC bearings [2,19,20]. Thirty studies reported revision rate of THA with MOM bearing [21-50], and 26 studies with COC bearing [51-76]. A total of 13,575 patients were included in our meta-analysis: 6215 patients in the MOM group and 7360 patients in the COC group.
Hard bearings, metal on metal (MOM) and ceramic on ceramic (COC), have been developed to overcome polyethylene wear-related osteolysis, but comparisons between these 2 hard bearings are limited. We performed a meta-analysis to determine revision rates for (1) any reason, (2) aseptic loosening, (3) periprosthetic joint infection (PJI), and (4) recurrent dislocation between MOM and COC bearings in cementless total hip arthroplasty.
This analysis included 3 studies comparing COC and MOM bearings and 56 studies reporting outcomes of MOM or COC bearings. We conducted a comparison meta-analysis (with a fixed-effects model) on the 3 comparative studies and a proportional meta-analysis on the data from the 59 articles to determine a consensus.
In the comparison meta-analysis, MOM showed higher revision rate than COC for any reason (odds ratio = 2.39, P = .046) and PJI (odds ratio = 6.21, P = .015). In the proportion meta-analysis, the MOM group showed significantly higher revision rate than COC group for any reason, aseptic loosening, and PJI.
MOM bearings were associated with a higher risk of revision for any reason and PJI than COC bearings after cementless total hip arthroplasty.
Excellent survivorship of the morscher monoblock cup with a 28-mm metasul-on-metasul bearing at a mean of 5-year follow-up
2014, Journal of Arthroplasty
The Morscher monoblock cup is designed for optimal osteointegration and holds the potential for excellent long-term survival. The Metasul-on-Metasul bearing was introduced to eliminate wear-induced periprosthetic osteolysis. This study reviews 137 Morscher cups with a 28-mm Metasul-on-Metasul bearing used in primary THA at 5.1 years (3.2–6.6) after implantation. One hundred thirty-seven cups were implanted in 119 patients. Three patients (2.2%) had died of unrelated causes, and 10 patients (8.0%) were lost to follow-up. The mean Harris Hip score was 89.8 and the mean WOMAC sum score was 18.5. No cases of acetabular osteolysis were found. The 5-year cup survival rate was 98.5%.
The Morscher cup with a 28-mm Metasul-on-Metasul bearing used in uncemented THA showed no acetabular osteolysis and promising survivorship at intermediate-term follow-up.
Poor short term outcome with a metal-on-metal total hip arthroplasty
2013, Journal of Arthroplasty
Citation Excerpt :
Several clinical trials have evaluated the short and intermediate term success with 28–32 mm MoM articulations used for THA. These studies have reported conflicting results with regard to success rates [17,28–31]. Larger head MoM studies have also been published [23,32,33], generally with less favorable results and higher revision rates.
Metal-on-metal (MoM) bearings for total hip arthroplasty (THA) have come under scrutiny with reports of high failure rates. Clinical outcome studies with several commercially available MoM THA bearings remain unreported. We evaluated 78 consecutive MoM THAs from a single manufacturer in 68 patients. Sixty-six received cobalt–chrome (CoCr) monoblock and 12 received modular titanium acetabular cups with internal CoCr liners. Femoral components were titanium with modular necks. At average 2.1 years postoperatively, 12 THAs (15.4%) demonstrated aseptic failure (10 revisions, 2 revision recommended). All revised hips demonstrated capsular necrosis with positive histology reaction for aseptic lymphocytic vasculitis-associated lesions/adverse local tissue reactions. Prosthetic instability following revision surgery was relatively common. Female gender was a strong risk factor for failure, though smaller cups were not. Both monoblock and modular components fared poorly. Corrosion was frequently observed around the proximal and distal end of the modular femoral necks.
The influence of head size on corrosion and fretting behaviour at the head-neck interface of artificial hip joints
2013, Journal of Arthroplasty
The primary goal of this study was to determine if head size affects corrosion and fretting behaviour at the head-neck taper interface of modular hip prostheses. Seventy-four implants were retrieved that featured either a 28 mm or a 36 mm head with a metal-on-polyethylene articulation. The bore of the heads and the neck of the stems were divided into eight regions each and graded by three observers for corrosion and fretting damage separately using modified criteria as reported in the literature. The 36 mm head size featured a significant difference in the corrosion head scores (p = 0.022) in comparison to the 28 mm heads. This may be attributed to a greater torque acting along the taper interface due to activities of daily living.

View all citing articles on Scopus

^☆: Benefits or funds were received in partial or total support of the research material described in this article. These benefits or support were received from Zimmer GmbH (Winterthur, Switzerland).

View full text

Metal-on-metal bearings in cementless primary total hip arthroplasty☆

Abstract

Section snippets

Material and methods

Complications

Dislocation with metal-on-metal bearings

Acknowledgements

J Arthroplasty

J Arthroplasty

The Swedish total hip replacement register

J Bone Joint Surg Am

Survival analysis of cementless grit-blasted titanium total hip arthroplasties

J Bone Joint Surg Br

Straight femoral taper in cementless primary total hip replacement in less than 65 year-old patientsmulticenter study of 115 consecutive implantations at mean 8.2 year follow-up

Rev Chir Orthop

Experience with the Metasul total hip bearing system

Clin Orthop

Metal degradation productsa cause for concern in metal-metal bearings?

Clin Orthop

Metallurgical considerations in the wear of metal-on-metal hip bearings

Hip International

Cotation chiffrée de la fonction de la hanche

Rev Chir Orthop